Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Whenever someone is scheduled for an operation, the assigned nurse is required to fill out a “pre-op checklist” to ensure that all safety and quality metrics are being adhered to. Before the patient is allowed to be wheeled into the OR we make sure the surgical site is marked, the consents are signed, all necessary equipment is available, etc. One of the most important metrics involves the peri-operative administration of IV antibiotics. SCIP guidelines mandate that the prophylactic antibiotic is given within an hour of incision time to optimize outcomes. This has been drilled into the heads of physicians, health care providers, and ancillary staff to such an extent that it occasionally causes total brain shutdown.

Let me explain. For most elective surgeries I give a single dose of antibiotics just before I cut. For elective colon surgery, the antibiotics are continued for 24 hours post-op. This is accepted standard of care. You don’t want to give antibiotics inappropriately or continue them indefinitely.

But what about a patient with gangrenous cholecystitis or acute appendicitis? What if, in my clinical judgment, I want to start the patient on antibiotics right away (i.e. several hours before anticipated incision time) and then continue them for greater than 24 hours post-op, depending on what the clinical status warrants? I should be able to do that right? [No - wrong - the idiots who designed your CPOE/Pharmacy IT system forgot that robotic medicine is bad medicine - ed.]

Well, you’d be surprised. [No, actually, I'm not. I'd have been more surprised to see a system not impeding critical medical decisions tailored to the individual patient - ed.]

You see, at two different, unaffiliated hospitals I cover, the surgeons have seen that decision-making capability removed from their power. If a young patient comes in with acute appendicitis and I feel that it would be prudent to continue the Zosyn an extra couple of days, an automatic stop order is triggered [presumably cybernetically - ed.] in the department of pharmacy and the antibiotic is stopped after 24 hours, no matter what. Unless the surgeon specifically writes “please do not stop this antibiotic after 24 hours; it is being administered for therapeutic purposes, not prophylaxis [that sounds a bit like begging - ed.] ,” the antibiotic will not be sent to the patient’s floor for administration. As a result, patients end up being treated sub-optimally, and potentially harmed, due to an over-emphasis on “protocol” and “quality care metrics.”

Similarly, the 60-minute timeline for pre-operative antibiotic administration can be problematic. I have had patients come into the ER with appendicitis or cholecystitis and, in my pre-op orders, write for Zosyn or whatever, to be started ASAP, no matter what time the operation is scheduled. Not too long ago, I admitted a gallbladder over the phone at 2am. I gave the nurse admitting orders which included one for a broad spectrum antibiotic.

When I saw the patient in the morning, I added her on to the OR schedule. By the time a room opened up, it was about 10:30am. The OR nurse asked me if I wanted to give an antibiotic for the case. I told her that the patient was already on antibiotics as part of her admit orders for treatment. The nurse shook her hand. It had never been given; the floor nurse held it so that it wasn’t administered until 60 minutes before the scheduled OR time, just like the algorithm dictates — despite the fact it had been ordered nearly 8 hours prior to the case, not for peri-op prophylaxis, but for treatment of an established pathology.[This is how EHR-induced malpractice occurs, readers. Guess who bears liability? - ed.]

And there it was, the cefotetan, hanging on her IV stand. Now nothing bad happened [this time, due to luck - ed.], but here you have a situation where health care providers are so terrified of violating Quality Assurance Protocol that they end up withholding necessary treatment. It’s just astounding. [It's astounding the surgeons don't simply use a scalpel on the computer terminal network and power cables to protect their patients - ed.]

As surgeons, we have bitched and moaned. You would think that these issues would be quickly rectified. But no. It is the responsibility of the surgeon to write qualifying statements [a workaround to a 'feature' that turns medical judgment on its head - ed.] for therapeutic antibiotics because the default mode is to override a licensed physician’s clinical judgment.[Not mentioned is who is overriding that judgment through cybernetic proxy - ed.]

This is what I’m talking about when I say that blind allegiance to a top-down, systems analysis-driven algorithm can turn everyone involved in health care into a bunch of mindless drones.

I will simply add that these issues sound like poor IT/protocol design and implementation, getting in a physician's way regarding tailoring of care to the individual patient.

An inviolable rule in health IT is - or needs to be -

"You should not have to work around something that is not in the way."

There is nothing to debate or discuss on this issue.

-- SS

Feb. 3, 2012 addendum:

Some IT person (anonymously, of course) tried to argue and debate anyway; however, they did not even do basic homework. See their comments in the comments box.

Feb. 5, 2012 addendum:

More in the comments section by someone saying they made the aforementioned comments, stating they are a hospitalist, and still trying to advance the same arguments in favor of physicians adapting to mission-hostile HIT and/or protocols rather than 'protesting too much.'

It is not sarcasm regarding IT at all. It is sarcasm regarding surgery. The article and the editor of this piece were complaining and making snarky comments about perioperative antibiotics. The arguments though do not hold water. Had the surgeon written the order properly and reviewed the patient's case, neither error would have occurred. We may grouse about algorithms and cookie-cutter medicine but the arguments in the article are not the ones to defend. And the algorithms would not be in place if physicians hadn't been making a legion of mistakes to begin with. And if anything these are not IT or system failures but nursing staff's for not clarifying the order, if it was written properly, which I doubt. Explain to me what is "remarkably inappropriate and puerile" about that. Is it the fact that I disagreed with you?

It's inappropriate to ignore the admonitions of clinicians regarding mission hostile IT, who know quite a bit more about medicine than you apparently do, and make puerile comments about doctors seeing patients every day.

Then, unknown's anonymity suggests the lack of fortitude to defend their views in the public eye.

Anonymous simply shows no understanding of mission hostile user experiences and the contribution to what NIST, among other organizations, calls "use error", where the IT contributes to (rather than decreasing) error.

There is no excuse for the lack of understanding, as I have posted an essay from the Air Force from three decades ago at my "mission hostile" series linked in this very post.

Put simply, it's not the physician's responsibility to work around poor IT. They have more important things to do. It's the IT designer and implemeter's responsibility to make IT usable, safe and dependable. I'd say the latter is something not really cared about, as at "A Study of an Enterprise Information System."

As I wrote, "You should not have to work around something that is not in the way."

There's nothing to debate here, and nothing to discuss.

Attitudes like those expressed by "anonymous" are why people like me will be cleaning their IT clocks in the courtroom, when a jury discovers just how much about Medical Informatics they don't know.

I must ask: why are so many corporate/hospital IT personnel this ignorant about HCI, and have such vicious attitudes about physicians and other clinicians whom they are supposed to serve in the latter's delivery of healthcare and sole assumption of risk?

I have no problem including my name and background. I did not include it previously because my ego is not invested in being a physician. I am a practicing hospitalist. I am not an IT guy but I work in a fully integrated system and I grouse about some of its shortcomings at times. But there is a point to algorithms and core measures and again, the article brings up weakly defensible positions. There are better ways to argue against IT's infiltration. Your over-the-top hostile response smacks of protesting too much. Your insults demonstrate the vacancy of your argument.

I have no problem including my name and background. I did not include it previously because my ego is not invested in being a physician. I am a practicing hospitalist.

Assuming you are who you say you are:

- If your ego is not invested in being a physician, i.e., advocating tirelessly for patients, then in what is it invested?

- You need to learn how to debate without invoking logical fallacy and hackneyed ad hominem attacks on "tone" instead of merit. Such arguments impress nobody in the blogosphere. The "tone" of my argument as you perceive it has nothing to do with its merit.

- You, in fact, invoked an insinuation that the surgeon who wrote the piece I quoted - and indeed all surgeons ("sarcasm regarding surgery") - are lazy and/or dull-minded for not simply adapting to whatever IT and/or protocols are thrown at them. You condemn doctors, especially surgeons, who are for the most part extremely dedicated and hardworking. To even go into the field of surgery is formidably demanding. If you are a medical professional, surely you know that. The purpose of HIT is to make their job easier, not harder.

- "My" argument is not about algorithms for decision support. It is about implementation that gets in the way of clinicians. What is described is not simply an alert and reminder system. It is a stark example of a "use error" (yes, use error, see NIST report as below) waiting to happen.

- "My" argument is not even mine. Read the resources I mention, such as my growing series on HIT that presents a profoundly mission-hostile user experience, the 1980's Air Force report on usability, the very recent NIST report on health IT usability specifically, and other resources linked to on this blog and on my didactic site such as the recent IOM report on health IT, the Joint Commission Sentinel Event Alert on HIT, the 2009 National Research Council report on HIT safety, the ECRI Institute top ten technology threats to healthcare safety, etc. as at this link for example.

- Regarding the "protesting too much", I submit proffering arguments in favor of patient safety is something that can never be done "too much."

- Regarding "better ways to argue against IT's infiltration", please reference those that have proven effective over the past 30+ years at ensuring HIT usability & safety. The HIT industry did not just start with the 2009 HITECH act that somehow found its way into ARRA.

Perhaps you believe physicians should just sit back and let others control medical care, while only 'protesting' in a genteel fashion.

Congratulations. You have actually started to present an argument. It is flawed, however, and still strewn with insults. But I do applaud the incremental improvement in tone. "Don't raise your voice. Improve your argument."Here's the flaw: you started out with a rail against IT in general and argued to throw out the baby with the bathwater. But the very problems mentioned in the article were dramatically more common with paper charts. IT is not perfect and it has been difficult for older, rigid physicians to adapt to the new technology. But it is much better than it had been. It is no longer plausible to practice without EMR/IT in a responsible way. Let's not forget that medication reconciliation was not even a factor 7 years ago, despite knowing it is a huge source of error. And it is clear that medical errors are legion. I personally have done a fair bit of surgery and have nothing against surgeons in general. They are not, however, known to be highly detail oriented when it comes to medication management, with the exception possibly of CT surgery.I do not believe physicians should sit back. But I also do not believe physicians should move backwards either. If you want to advocate for patients you will advocate for a system that overall reduces errors and you will guide that system to be even better. I'm sure there was a time when a group of physicians did not see a point in x-rays because they felt auscultation could tell them what they needed to know. Advocating a better system is about your patients and their safety and the efficacy of your practice. Ego is about you. It is artificial to conflate them. It is only delusion at its core anyway.I have worked with 5 EMR's, including the VA system and some are clearly better than others and we can talk all day about the VA's failings. But all of these EMR's are a sea change compared to traditional charting. Interpreting handwriting, inability to access data, data locked in multiple locations, interpretation errors, data loss, chart volume, paper use, photocopying, lack of chart transferability when patient transfers, errors, errors, errors. Argue for improvement of an already improved system not a return to a clearly inferior one. Despite an improved system we still have to protect our patients from the assaults of entropy. And treatment algorithms dramatically improve patient care as well. Read one article of Peter Pronovost. Our biggest advances in the near future will come from standardization of what we do and routinely doing what we know works, not by newer treatment advances. The article complains about getting a patient the antibiotic, but before the algorithm (SCIP) in the first place, half of the surgical patients or less were getting antibiotics at all.

If you think it's not, then you have failed to do a simple perusal of this blog's pages which would have led you here.

But that's not important now.

What is important:

I believe we'll have to disagree on "tone." I make spirited arguments; you obviously prefer a genteel style - except, apparently, when expressing prejudicial views against the busiest, most hardest-working, and miost liability-prone of all clinicians, namely surgeons (see below). Note: I am not a surgeon; I trained in IM and then Medical Informatics.

On the other hand, you have not responded to any of my arguments, nor my linked essays or literature references, nor to my condemnation of your invective against surgeons, both the individual who posted his complaints, and surgeons as a class. That is mean-spirited prejudice.

You have not responded to my question about your statement that your "ego is not invested in being a physician." That, to me, is quite alien to medicine, and I would like an explanation.

You have not responded to my points about obstructive IT and processes. Instead, you deviate to the tangential and somewhat non-sequitur claim that paper is out-and-out inferior. Further, you state that I "started out with a rail against IT in general and argued to throw out the baby with the bathwater."

That, however, is a classic strawman fallacy (link), as I am a strong supporter of health IT and never stated or implied what you claim.

I am not a supporter of subotimal HIT, however. HIT medical devices cannot improve healthcare outcomes if it itself is not improved, and in fact may set back the cause of better HC delivery. See for example the NRC report of 2009 - led by two of the Medical Informatics pioneers, Octo Barnett and Bill Stead, along with a plethora of multidisciplinary experts. This is not an appeal to authority, but an appeal for you to, once again, do some reading.

Your personal views on HIT medical devices are interesting, and you are entitled to them, but do not at all address my argument that HIT or manual processes that present a mission hostile user experience and promote "use error" can be quite harmful. Further, your views seem to be supported by n=1, as you have not provided any substantive references to back your assertions.

On the other hand, I have now posted links to 9 or more essays on the issue of mission hostile IT, themselves with hyperlinks to other material, and to over fifty articles in the literature, most of then peer-reviewed. You have not responded to any of them.

But all of these EMR's are a sea change compared to traditional charting. Interpreting handwriting, inability to access data, data locked in multiple locations, interpretation errors, data loss, chart volume, paper use, photocopying, lack of chart transferability when patient transfers, errors, errors, errors. Argue for improvement of an already improved system not a return to a clearly inferior one.

First: "all of these EMRs"? Have you seen and used each and every one? Based on what do you support that particular contention? That is, I think we can agree, a reasonable question.

Second: if you'd read my many references, you'd know that the research supporting your contentions overall, and more importantly the outcomes results of IT compared to paper, are (at best) contradictory. The key to putting this issue in context is to understand that I am referring to today's health IT.

Also, please review my references and let me know that you understand the medical error and harm rates and magnitudes caused by or contributed to by IT. I think we can agree it should be an easy number to find, since the technology has been cleared for national rollout.

Also point out any RCT's (the gold standard, of course, as opposed to weak retrospective observational studies) you know of where that issue, and the issue of paper vs. HIT medical devices, is studied. Those should be, per human subjects research protocols and medical ethics, plentiful and conclusive as well, like with drugs and other medical devices. Agree? For that matter, although as I wrote was a tangential point to may actual arguments, please provide references to the frequency and magnitude of errors caused by paper records.

On the basis of what you find, please then justify the ethical rationale for a national rollout of health IT in 2012 (actually, initiated in earnest in 2009).

Please do not go off on other tangents without responding to the issues I've now repeated multiple times - the substance of my arguments - about mission hostile IT, its promotion of use error, and other informational tools and processes such as protocols implemented in a ham-fisted manner that interfere with patient care.

When I say there's nothing to debate and nothing to argue on that issue, I'm not being hyperbolic.

You seem to have me confused with a post-doc working on your anti-EMR thesis.I also encourage you to reread my post for much of what you say takes me out of context and is factually not true about my statements and what I have responded to. Again, I have nothing against a thoughtful, careful surgeon. Some of the best physicians I know have been. Nevertheless, your argument is starting to become more nuanced and therefore correct and coming around to my original points.With regard to your referenced multiple opinion pieces, and attempts at data, they themselves point to a lack of data one way or the other. But we should not equate the lack of evidence with evidence of a lack. Nor should we posit opinion pieces and essays as data points.I do not and have not denied that there are problems associated with EMR's. But I remember much bigger problems prior and many of these problems were swept under the rug. Now we have everything recorded. Gathering reliable comparative data under these circumstances will never be possible. Therefore reason must prevail, as it must when we practice but lack an evidence base to make decisions. My arguments therefore are straight to the point, not tangential. It is amusing that I am accused of ad hominem attacks when you have repeatedly called my personal credibility and identity into question. "Why do you look at the speck of sawdust in your brother's eye and pay no attention to the plank in your own eye?"Your general reaction/tone is also surprising given your articles reporting you to be "deliberately provocative." Provocative, by definition, is designed to provoke a response, and typically a contrary one. Thus, surprise at your success?EMR has been glommed onto by physicians and it has been forced upon them both. Physicians have increasingly greater amounts of information to manage and it is no longer feasible to do this as it was before. There is no going back now. Longer survival, multiple chronic conditions, increasingly complicated treatments, imaging, specialty involvement are all dramatically increasing the amount of data we need to process. Much of this was just overlooked in the past, causing a degree of error that by its nature could never even be appreciated. But managing data load can be difficult and failure to adapt will have significant consequences. EMR makes this somewhat easier but it is not a license to be superficial when it comes to patient care. The same diligence in patient safety must be employed as ever before. Medication lists must still be reviewed. Patients must still be watched closely, despite the temptation with EMR to try to place them on autopilot. Reams of prn orders to cover every conceivable post-op symptom such that the nurse never has to bother the physician with a phone call helps ensure "learned physician helplessness" against which you rightly rail. Orders are written in seconds now, when minutes were used before. That begs the question of how much less thought is employed in the process of the order writing. However, errors as a consequence of not having to answer the page, not knowing what happened overnight, and less thought put into orders still comes down to an indictment of the physician who abdicated his responsibility to the patient. Preprogrammed order sets and checklists make life easier and demonstrably safer but if you do not make it plain when you wish to deviate from that order set you will have problems.

In many ways it is the very power of the EMR that makes physicians drunk with it. It is difficult to indict the EMR for that, however cumbersome the program may be. I can agree with the post that the FDA may have a role in regulation of EMR. The technology is still in its infancy and we should continue to push to eliminate its faults and further enhance its benefits and push for standardization. But rejecting it outright, which you are appropriately stepping back from is not the answer. I am sure the cavemen did not reject fire at first because it burned fingers in the absence of data for it.

Indeed I did respond to the ego question, but I will try to make it even more plain. My quality, care, compassion, and skill as a physician are independent qualities from my ego. Ego only compromises these factors. It makes me try to protect my preconceived notions of my personal value and tie it to something that is irrelevant to it e.g. being a physician. It tempts me to try to protect my preconceived notion of self rather than recognize areas of deficiency in my quality, compassion, care and thus improve them. It makes me protect myself, makes me rigid in my care, and stands in the way of my patient's care. Removing my ego as a physician provides a lot more room for the patient's ego in the process and makes me markedly more effective in guiding the patient toward the most optimal care. My drive for excellence in medicine does not originate from my ego. That is a trick of the ego. My drive for excellence is based on my compassion for the patient, fear of making a mistake, and the love of medicine for medicine's sake. Ego is a delusion that only leads to suffering and it should be minimized or eliminated for our own sakes and for those with whom we interact. Ego in medicine is particularly insidious and it is often the unrecognized devil at the heart of medical errors.

You still haven't answered most of my questions. It sounds like you simply will not, so I will only repeat one.

First, I will answer one, though. The degree of harms of HIT is admittedly unknown, due to impediments to information flow. FDA, IOM, JC and others have explicitly admitted this.

Therefore it is impossible to state with certainty that the technology is, or is not, superior to anything. Also, the attitude of trading one set of ills for another (admittedly unknown) set is not medically ethical.

I still would like to know why you think a national rollout of unregulated HIT medical devices at their current stage of development (yes, medical devices per FDA, SMPA and others), when the literature shows significant conflict on benefit/risks, and where patient consent is not sought on what amount to human subjects experiments, is ethical.

re: But rejecting it outright, which you are appropriately stepping back from is not the answer

Although expressed in a somewhat ill-informed fashion, I'll take that as a weak compliment. "Stepping back from" is ill-informed, since my POV has been well-expressed in my multiple thousands of pages of writing. "Health IT can accomplish all that is claimed of it - but only if done well."

You can see this line in the main essay at my now-12 year old website on HIT difficulties at Drexel University here as:

"While clinical IT is now potentially capable of achieving many of the benefits long claimed for it such as improved medical quality and efficiency, reduced costs, better medical research and drugs, earlier disease detection, and so forth, there is a major caveat and essential precondition: the benefits will be realized only if clinical IT is done well. For if clinical IT is not done well, as often occurs in today’s environment of medical quick fixes and seemingly unquestioning exuberance about IT, the technology can be injurious to medical practice and biomedical R&D, and highly wasteful of scarce healthcare capital and resources."

Re: My drive for excellence in medicine does not originate from my ego.

We are in agreement there. Thanks for the explanation.

Ego in medicine is particularly insidious and it is often the unrecognized devil at the heart of medical errors.

I also agree.

However, there is another issue of a similar kind with regard to actual expertise. It can afflict those in HIT without medical backgrounds, and those in medicine without IT backgrounds (or, more importantly, biomedical informatics backgrounds).

It is, in essence, a phenomenon of not knowing the limits of one's own expertise, and not recognizing that those limits exist.

If you have no formal education or research/practical expertise in IT or healthcare informatics, and correct me if I am mistaken, nor have read extensively in the domain (you still do not acknowledge the material at my extensive links), you should perhaps be more humble in promoting your views.

If someone is harmed due to an IT-related error, and you were the physician of record, you will likely be decimated in court with those attitudes. I know, because I am a plaintiff's expert witness on health IT related med mal and record spoliation, a field in which I got started after my relative's devastating injuries in a HIT-related incident in 2010.

Wikipedia: Although the Dunning–Kruger effect was put forward in 1999, David Dunning and Justin Kruger have quoted Charles Darwin ("Ignorance more frequently begets confidence than does knowledge") and Bertrand Russell ("One of the painful things about our time is that those who feel certainty are stupid, and those with any imagination and understanding are filled with doubt and indecision") as authors who have recognised the phenomenon.

I have found that the insidious preprogrammed stop orders are particularly dangerous. The doctor never knows where they are unless the lines of legible gibberish are all read. There are also innumerable other idiosyncrasies in orders that endanger patients; sometimes killing them.

That is why the FDA should be providing premarket assessment and post market surveillance of these devices.

The doctor never knows where they are unless the lines of legible gibberish are all read. There are also innumerable other idiosyncrasies in orders that endanger patients; sometimes killing them.

These issues are largely in the realm of information science and HCI.

Unfortunately, in health IT, amateurs with regard to those domains reign supreme. The HIT industry is decades behind others in that regard. They are "still learning" how to do HIT "right." despite decades of marketing and decades of literature on how to do so.

Even attorneys are having very difficult time figuring out what happened in a clinical case from the outputs of today' EHRs. The outputs violate fundamental precepts of medical record keeping, presentation of information, and more generally, information science.

A data dump may help justify billing, but heaven help any busy physician trying to make sense of it.

In that, I have personal experience. It led to a warning letter to a hospital about exactly that issue, a letter that as ignored just a month before a relative of mine was seriously injured as a result of EHR interference in information flows.

You seem to have me confused with a post-doc working on your anti-EMR thesis.

On the issue of accusations of health IT negativity, see the comment thread here.

When facts get in the way of subjective opinions, that's called "science." While evidence-based medicine is promoted, evidence-based IT practice is not. The IT quality and fitness for purpose remains static as a result.

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